Jones Metal Products Medical Benefits
Summary of Medical Benefits
HDHP 1
| In-Network | Out-Of-Network | |
|---|---|---|
| Plan Year Deductible | $1,650 Individual/ $3,300 Family |
$3,000 Individual/ $6,000 Family |
| Plan Year Out of Pocket | $3,300 Individual/ $6,600 Family |
$8,000 Individual/ $16,000 Family |
| Primary Care Office Visit | $0 After Deductible | 25% After Deductible |
| Specialist Office Visit | $0 After Deductible | 25% After Deductible |
| Preventive Care/Screenings/Immunization | Covered at 100% | 50% Deductible waived |
| Diagnostic Testing: Lab, X-Ray | $0 After Deductible | 25% After Deductible |
| Complex Imagining (MRI, PET/CT) | $0 After Deductible | 25% After Deductible |
| Outpatient Surgery | $0 After Deductible | 25% After Deductible |
| Inpatient Hospital | $30 After Deductible | 25% After Deductible |
| Urgent Care | $0 After Deductible | 25% After Deductible |
| Virtual Visits | $0 Copay | 25% Copay |
| Emergency Room | $0 After Deductible | $0 After In-Network Deductible |
| Rehabilitation Services (PT/OT/SP)-Limit 30 visits | $0 After Deductible | 25% After Deductible |
| Pharmacy | ||
|---|---|---|
| RX Deductible | Integrated with Medical | |
| Retail (30 Day Supply) | Generic - $10 Copay After Deductible Preferred Brand - $25 Copay After Deductible Non-Preferred Brand - 50% After Deductible Specialty Drugs - $150 Copay After Deductible |
|
| Mail Order (90 Day Supply) | Generic - $20 Copay After Deductible Preferred Brand - $50 Copay After Deductible Non-Preferred Brand - $150 Copay After Deductible |
|
| Out of Network Pharmacy | ||
|---|---|---|
| Plan Year Deductible | $3,000 Individual/$6,0000 Family | |
| Member Coinsurance | 75% | |
| Plan Year Out of Pocket | $8,000 Individual/$10,000 Family | |
To learn more about your plan, please review your Summary of Benefits and Coverage (SBC) for a high-level overview of your coverage or the Summary Plan Document (SPD) for the detailed plan description and guidelines
Important Plan Documents